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1.  Improving Patient Care Using the Johnson-Neyman Analysis of Heterogeneity of Treatment Effects According to Individuals' Baseline Characteristics 
Because each patient’s baseline (pre-treatment) characteristics differ (e.g., age, sex, socioeconomic status, ethnicity/race, biomarkers), treatments do not work the same for every patient-some can even cause detrimental effects. To improve patient care, it is critical to identify such heterogeneity of treatment effects. But the standard analytic approach dichotomizes baseline characteristics (low vs. high) which often leads to a loss of critical patient-care information and power to detect heterogeneity, as the results may depend strongly on the cut-points chosen. A more powerful analytic approach is to analyze baseline characteristics (i.e., covariates) measured on a continuous scale that retains all of the information available for the covariate.
In this article, we show how the Johnson-Neyman (J-N) method can be used to identify the prognostic and predictive value of baseline covariates measured on a continuous scale - findings that often cannot be determined using the traditional dichotomized approach. As an example, we used the J-N method to explore treatment effects for varying levels of the biomarker salivary mutans streptococci (MS) in a randomized clinical prevention trial comparing fluoride varnish with no fluoride varnish for 376 initially caries-free high-risk children, all of whom received oral health counseling.
The J-N analysis showed that children with higher baseline MS values who were randomized to receive fluoride varnish had the poorest dental caries prognosis and may have benefitted most from the preventive agent.
Such methods are likely to be an important tool in the field of personalized oral health care.
PMCID: PMC4335806
Fluoride varnish; interaction; Johnson-Neyman method; salivary mutans streptococci; subgroup analysis; treatment-effect heterogeneity; personalized medicine; precision medicine
2.  Dental utilization by children in Hispanic agricultural worker families in California 
Agricultural worker families encounter multiple barriers to accessing all needed dental care. This study investigated predisposing, enabling, and need factors associated with children's past year dental utilization among Hispanic agricultural worker families in central California.
Oral health survey and clinical data were collected from families participating in a larger, population-based study in 2006-7. Generalized estimating equation logit regression assessed effects on a dental visit among children aged 0-17 (n=405). Analyses adjusted for clustering of children in the same household. Predisposing (sociodemographics), enabling (child's dental insurance, usual source of dental care, caregiver past year dental visit, acculturation level, income and education), and need (caregiver's oral health rating, perception of cavities, and clinically-determined treatment urgency) factors were examined.
Half (51%) the children had a past year dental visit, while 23% had never been to a dentist. In the final model, children were less likely to have a past year dental visit if they were foreign-born, male, had caregivers that thought they had cavities or were unsure, and if the dentist recommended treatment ‘at earliest convenience’. Children aged 6-12, with a regular dental care source, and whose caregivers had a recent dentist visit were more likely to have a past year dental visit.
Children were more likely to have a past year dental visit if they had a usual source of dental care (OR =4.78, CI=2.51-9.08), and if the caregiver had a past year dental visit (OR=1.88, CI=1.04-3.38). Emphasis should be placed on these two modifiable factors to increase children's dental utilization.
PMCID: PMC4301614  PMID: 25621285
Cross-Sectional Studies/utilization; Dental Health Surveys/utilization; Hispanic Americans
3.  Recruiting and retaining pregnant women from a community health center at the US–Mexico border for the Mothers and Youth Access clinical trial 
Recruitment and retention in clinical trials of minorities is low, particularly in rural underserved populations. This has slowed progress in addressing racial/ethnic disparities in oral health.
To describe factors associated with successful recruitment, and identify predictors of continued retention of pregnant women attending a community health center into a randomized controlled clinical trial to prevent early childhood caries.
The Mothers and Youth Access (MAYA) Trial recruited women in the second trimester of pregnancy. At baseline, consenting women completed an oral health questionnaire and received a dental exam and oral health counseling. Four months postpartum, women returned with their babies for randomization with follow up at 9-, 12-, 18-, 24-, 30-, and 36-month postpartum visits. To assess predictors of retention, data about respondents’ demographics, and oral health-related knowledge, attitudes, and behaviors were obtained by questionnaire and analyzed by logistic and discrete time-to-event regression analyses.
Of 556 predominantly Mexican-American women recruited at baseline, 195 (35%) were excluded after baseline for not meeting inclusion criteria; 361 (65%) continued to randomization. Factors such as race/ethnicity, annual household income, household composition, oral health-related knowledge and behaviors significantly related to retention until randomization. In multivariable models, women reporting a higher annual household income were less likely to be lost to attrition before randomization (odds ratio = 0.73, 95% confidence interval (CI) 0.60–0.89); while Mexican/Mexican-American women were less likely to be lost beyond randomization (hazard ratio = 0.53, 95% CI 0.26–1.08).
Factors not measured at baseline may have been important in predicting attrition. The MAYA Trial is expected to finish by November 2008; therefore, complete results for total retention may differ from those reported here.
Recruitment and retention efforts for pregnant Hispanic women should place heavy emphasis on culture as ethnicity remained the only borderline significant predictor in post randomization retention.
PMCID: PMC4238942  PMID: 18697848
4.  Clinically Determined and Self-Reported Dental Caries Status During and After Pregnancy Among Low-Income Hispanic Women 
This analysis assessed, during and one-year after pregnancy: 1) the prevalence of and relationship between self-reported and clinically determined dental caries and oral health status, and whether self-reports are a potential proxy for professional determination; 2) factors associated with high levels of professionally determined or self-reported oral disease.
Data are from a randomized clinical trial of 301 pregnant, low-income Hispanic women at the California-Mexico border to compare two interventions to prevent early childhood caries. Interviews and dental examinations were conducted at enrollment (second trimester) and one-year post-partum (PP).
During pregnancy and PP, 93% had untreated caries and most had gingival inflammation. Sensitivity and specificity of self-reported measures compared to dentists’ determinations were modest (ranging from 45–80% for sensitivity and 41–77% for specificity at both time points); positive predictive values for women reporting current tooth decay or fair/poor oral health were high (>94%), but negative predictive values were low (<23%). In a bivariate GEE model, factors associated with fair/poor self-reported oral health during and after pregnancy included self-reported dental symptoms (current tooth decay, bleeding gums without brushing), dental behaviors (not flossing) and number of decayed tooth surfaces. In a logistic regression model, the only significant factor PP associated with less extensive untreated disease was if women ever had their teeth cleaned professionally (OR=0.44).
There is a great need for dental treatment in this underserved population both during pregnancy and PP. Women may not be able to accurately recognize or act on their treatment needs. At baseline and PP, few demographic or behavioral factors were associated with either self-reported or clinically-determined oral disease (e.g., being less educated or acculturated and not flossing) in the bivariate analyses. Ever having a professional teeth cleaning significantly predicted less disease PP.
PMCID: PMC3990252  PMID: 23889689
pregnancy; dental caries; oral health; post-partum; health status disparities; Hispanic
5.  The effect of training on the use of tobacco-use cessation guidelines in dental settings 
An increase in the number of dentists conducting tobacco-use cessation treatment is needed. The authors assessed the effects of high-intensity training (HIT) or low-intensity training (LIT) and reimbursement on general dentists’ tobacco-use–related attitudes and treatment behaviors.
The authors randomly selected 265 dentists in three states and assigned them to one of five groups: HIT workshop groups with and without tobacco-use cessation counseling reimbursement, LIT mailed self-study groups with and without reimbursement or a control group. Outcomes at follow-up were dentists’ self-reported tobacco-use–related attitudes and behaviors and patients’ reports of dentists’ behaviors.
Significantly more dentists in the intervention groups reported having positive attitudes and behaviors at follow-up than did dentists in the control group. Dentists in the HIT groups, however, reported assessing patients’ willingness to quit and assisting them with the quitting process significantly more often than did dentists in the LIT groups. Significantly more patients of dentists in the intervention groups who used tobacco reported receiving advice and assistance from their dentists than did patients of dentists in the control group. Adding reimbursement to HIT or LIT conditions did not provide additional intervention effect.
Dentists trained by means of a workshop or self-study program used components of a recommended guideline more frequently and felt more positive toward tobacco-use cessation counseling than did dentists in the control group.
Clinical Implications
Although the workshop training was more successful than the self-study training, the latter’s reach among dentists could have a more significant public health impact. The effect of reimbursement needs further study.
PMCID: PMC4130169  PMID: 22653940
Tobacco-use cessation; dental team; dental offices
6.  Dentists’ attitudes, behaviors, and barriers related to tobacco-use cessation in the dental setting 
This study assessed attitudes, behaviors, and barriers among general dentists in California, Pennsylvania, and West Virginia, related to patient tobacco cessation counseling.
From 2004 to 2008, a baseline survey was mailed to 271 study dentists randomly selected from a master Delta Dental Insurance Company provider list in each state who had agreed to participate in a tobacco cessation randomized clinical trial. Four backward logistic regression models assessed correlates of the five As related to tobacco cessation: Asking about tobacco use, Advising users to quit, Assessing readiness to quit, Assisting with quitting, and Arranging follow-up.
Most respondents (n = 265) were male, had practiced dentistry for over 15 years, asked about tobacco use (74%), and advised tobacco users to quit (78%). Only 19% assessed readiness to quit; 39% assisted with quitting; 4% arranged follow-up; and 42% had formal training in tobacco cessation. Believing that tobacco cessation counseling was an important professional responsibility, practicing <15 years, and asking about tobacco use significantly related to advising users to quit. Providing cessation advice and feeling effective intervening related to assessing readiness to quit. Advising users to quit, assessing readiness to quit, feeling effective intervening, and having had formal tobacco cessation training related to assisting with quitting. Barriers to cessation counseling were perceived patient resistance (66%), lack of insurance reimbursement (56%), not knowing where to refer (49%), and lack of time (32%).
Study dentists reported not fully performing the five As. Advising, assessing, having formal training, and feeling effective increased the likelihood of cessation counseling.
PMCID: PMC4028076  PMID: 22731618
tobacco cessation; dentists; dental practices; survey
7.  An Examination of Racial/Ethnic Disparities in Children’s Oral Health in the United States 
Assess the extent apparent racial/ethnic disparities in children’s oral health and oral health care are explained by factors other than race/ethnicity.
Data Source
2007 National Survey of Children’s Health, for children 2–17 years (N=82,020). Outcomes included parental reports of child’s oral health status, receipt of preventive dental care, and delayed dental care/unmet need. Model-based survey data analysis examined racial/ethnic disparities, controlling for other child, family, and community/state (contextual) factors.
Unadjusted results show large oral health disparities by race/ethnicity. Compared to non-Hispanic Whites, Hispanics and non-Hispanic Blacks were markedly more likely to be reported in only fair/poor oral health (odds ratios (ORs) [95% confidence intervals] 4.3 [4.0–4.6], 2.2 [2.0–2.4], respectively), lack preventive care (ORs 1.9 [1.8–2.0], 1.4 [1.3–1.5]), and experience delayed care/unmet need (ORs 1.5 [1.3–1.7], 1.4 [1.3–1.5]). Adjusting for child, family, and community/state factors reduced or eliminated racial/ethnic disparities. Adjusted ORs (AORs) for Hispanics and non-Hispanic Blacks attenuated for fair/poor oral health, to 1.6 [1.5–1.8] and 1.2 [1.1–1.4], respectively. Adjustment eliminated disparities in each group for lacking preventive care (AORs 1.0 [0.9–1.1], 1.1 [1.1–1.2]), and in Hispanics for delayed care/unmet need (AOR 1.0). Among non-Hispanic Blacks, adjustment reversed the disparity for delayed care/unmet need (AOR 0.6 [0.6–0.7]).
Racial/ethnic disparities in children’s oral health status and access were found to be attributable largely to determinants such as socioeconomic and health insurance factors. Efforts to decrease disparities may be more efficacious if targeted at the social, economic, and other factors associated with minority racial/ethnic status, and may also have collateral positive effects on sectors of the majority population who share similar social, economic and cultural characteristics.
PMCID: PMC3702186  PMID: 22970900
children; oral health; race/ethnic disparities
8.  Racial Disparity Trends in Children’s Dental Visits: US National Health Interview Survey, 1964–2010 
Pediatrics  2012;130(2):306-314.
Research that has repeatedly documented marked racial/ethnic disparities in US children’s receipt of dental care at single time points or brief periods has lacked a historical policy perspective, which provides insight into how these disparities have evolved over time. Our objective was to examine the im-pact of national health policies on African American and white children’s receipt of dental care from 1964 to 2010.
We analyzed data on race and dental care utilization for children aged 2 to 17 years from the 1964, 1976, 1989, 1999, and 2010 National Health Interview Survey. Dependent variables were as follows: child’s receipt of a dental visit in the previous 12 months and child’s history of never having had a dental visit. Primary independent variable was race (African American/white). We calculated sample prevalences, and χ2 tests compared African American/white prevalences by year. We age-standardized estimates to the 2000 US Census.
The percentage of African American and white children in the United States without a dental visit in the previous 12 months declined significantly from 52.4% in 1964 to 21.7% in 2010, whereas the percentage of children who had never had a dental visit declined significantly (P < .01) from 33.6% to 10.6%. Pronounced African American/white disparities in children’s dental utilization rates, whereas large and statistically significant in 1964, attenuated and became nonsignificant by 2010.
We demonstrate a dramatic narrowing of African American/white disparities in 2 measures of children’s receipt of dental services from 1964 to 2010. Yet, much more needs to be done before persistent racial disparities in children’s oral health status are eliminated.
PMCID: PMC3408679  PMID: 22753556
children; racial disparities; dental care; NHIS
9.  Mother and Youth Access (MAYA) Maternal Chlorhexidine, Counseling and Pediatric Fluoride Varnish Randomized Clinical Trial to Prevent Early Childhood Caries 
Mexican-American children have a higher caries prevalence than the US average. The Mothers and Youth Access (MAYA) study was a randomized clinical trial initiated to address this problem.
Comparison of the efficacy of two prevention interventions in reducing early childhood caries (ECC).
All 361 randomized mother-child dyads received oral health counseling. Beginning at 4 months postpartum, intervention mothers received chlorhexidine (CHX) mouthrinse for 3 months beginning 4 months postpartum and children received fluoride varnish (FV) every 6 months from age 12–36 months. Control group children received FV if precavitated lesions developed. Salivary mutans streptococci (MS) and lactobacilli were assessed.
No significant difference in children’s 36-month caries incidence between groups; 34% in each group developed caries ((d2+fs) > 0). About half of control group developed precavitated lesions and received therapeutic FV. Maternal MS levels declined during CHX use, but increased when discontinued.
Maternal postpartum CHX regimen, oral health counseling, and preventive child FV applications were not more efficacious than maternal counseling with child therapeutic FV for precavitated lesions for ECC prevention. FV for young children with brief maternal CHX use and oral health counseling may need to be combined with additional or longer-term therapies to significantly reduce ECC in high-risk populations.
PMCID: PMC3277669  PMID: 21999806
Epidemiology; Fluoride; Perinatal; Oral Health; Infant; Early Childhood Caries; Randomized Clinical Trial; Chlorhexidine; Prevention
10.  Water consumption beliefs and practices in a rural Latino community: Implications for fluoridation 
Adequate fluoride exposure is especially important for those experiencing disproportionately high prevalence of dental caries, such as rural Latino farmworkers and their children. Water is an important source of fluoride. This qualitative study examined water consumption beliefs and practices among Latino parents of young children in a rural community.
Focus groups and open-ended in-depth interviews explored parents’ beliefs about tapwater, beverage preferences and knowledge of fluoride. A questionnaire documented socio-demographic characteristics and water consumption practices. Qualitative analysis revealed how water-related beliefs, social and cultural context, and local environment shaped participants' water consumption.
The vast majority of participants (N=46) avoided drinking unfiltered tap water based on perceptions that it had poor taste, smell and color, bolstered by a historically justified and collectively transmitted belief that the public water supply is unsafe. Water quality reports are not accessible to many community residents, all of whom use commercially bottled or filtered water for domestic consumption. Most participants had little knowledge of fluoride beyond a general sense it was beneficial. While most participants expressed willingness to drink fluoridated water, many emphatically stated that they would do so only if it tasted, looked, and smelled better and was demonstrated to be safe.
Perceptions about water quality and safety have important implications for adequate fluoride exposure. For vulnerable populations, technical reports of water safety have not only to be believed and trusted but matched or superceded by experience before meaningful change will occur in people’s water consumption habits.
PMCID: PMC3536824  PMID: 20735717
Hispanic Americans; rural population; dental caries; water; culture
11.  Dental utilization among Hispanic adults in agricultural worker families in California's Central Valley 
To examine past year dental visits among underserved, Hispanic farmworker families using the Andersen Behavioral Model of Health Services Utilization (1968), which posits that predisposing, enabling, and need factors influence care-seeking behavior.
Oral health survey and clinical data were collected in 2006-7 from families in Mendota, California (Fresno County) as part of a larger, population-based study. Generalized estimating equation logit regression assessed effects of factors on having a dental visit among adults (N=326). Predisposing variables included socio-demographic characteristics, days worked in agriculture, self-rated health status, and dental beliefs. Enabling factors included resources to obtain services (dental insurance, income, acculturation level, regular dental care source). Need measures included perceived need for care and reported symptoms, along with clinically-determined untreated caries and bleeding on probing.
Only 34% of adults had a past year dental visit, despite 44% reporting a regular dental care source. Most (66%) lacked dental insurance, and nearly half (46%) had untreated caries. Most (86%) perceived having current needs, and on average, reported a mean of 4.2 dental symptoms (of 12 queried).
Regression analyses indicated those with more symptoms were less likely to have a past year dental visit. Those who would ask a dentist for advice and had a regular dental care source were more likely to have a past year dental visit.
The final model included predisposing, enabling and need factors. Despite low utilization and prevalent symptoms, having a regular source of care helps break this pattern and should be facilitated.
PMCID: PMC3462228  PMID: 20545826
dental health services; Hispanic; agricultural workers
13.  Sustainable Oral Health Interventions 
Journal of public health dentistry  2011;71(Suppl 1):S95-S96.
PMCID: PMC3111948  PMID: 21656963
oral health; interventions; program sustainability; public health; dental health services
14.  Most Pregnant Women in California Do Not Receive Dental Care: Findings from a Population-Based Study 
Public Health Reports  2010;125(6):831-842.
We examined the prevalence of dental care during pregnancy and reasons for lack of care.
Using a population-based survey of 21,732 postpartum women in California during 2002–2007, we calculated prevalence of dental problems,receipt of care, and reasons for non-receipt of care. We used logistic regression to estimate odds of non-receipt of care by maternal characteristics.
Overall, 65% of women had no dental visit during pregnancy; 52% reported a dental problem prenatally, with 62% of those women not receiving care. After adjustment, factors associated with non-receipt of care included non-European American race/ethnicity, lack of a college degree, lack of private prenatal insurance, no first-trimester prenatal insurance coverage, lower income, language other than English spoken at home, and no usual source of pre-pregnancy medical care. The primary reason stated for non-receipt of dental care was lack of perceived need, followed by financial barriers.
Most pregnant women in this study received insufficient dental care. Odds were elevated not only among the poorest, least educated mothers,but also among those with moderate incomes or some college education.The need for dental care during pregnancy must be promoted widely among both the public and providers, and financial barriers to dental care should be addressed.
PMCID: PMC2966664  PMID: 21121228
15.  Assessing a multilevel model of young children’s oral health with national survey data 
To empirically test a multilevel conceptual model of children’s oral health incorporating 22 domains of children’s oral health across four levels: child, family, neighborhood and state.
Data source
The 2003 National Survey of Children’s Health, a module of the State and Local Area Integrated Telephone Survey conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics, is a nationally representative telephone survey of caregivers of children.
Study design
We examined child-, family-, neighborhood-, and state-level factors influencing parent’s report of children’s oral health using a multilevel logistic regression model, estimated for 26 736 children ages 1–5 years.
Principal findings
Factors operating at all four levels were associated with the likelihood that parents rated their children’s oral health as fair or poor, although most significant correlates are represented at the child or family level. Of 22 domains identified in our conceptual model, 15 domains contained factors significantly associated with young children’s oral health. At the state level, access to fluoridated water was significantly associated with favorable oral health for children.
Our results suggest that efforts to understand or improve children’s oral health should consider a multilevel approach that goes beyond solely child-level factors.
PMCID: PMC3025295  PMID: 20370808
children’s oral health; multilevel modeling; multiple imputation
16.  Parental Perception of Oral Health Status of Children in Mainstream and Special Education Classrooms 
The aim of this study was to compare parental perceptions of oral health status and access to dental services by children in 34 special education and 16 mainstream public elementary school classes in San Mateo County, CA. A self-administered parental survey was utilized and included questions about demographics, oral health and dental utilization. The overall response rate was 58.8%. After adjusting for age and gender of the child, compared to mainstream, parents of special education students were significantly more likely to report their child to have: worse oral health (OR= 2.4, 95% CI 1.54, 3.67) lacking a past year dental visit (OR= 1.96, 95% CI 1.01, 3.84), and missed school days due to dental reasons (OR = 2.5, 95% CI 1.55, 4.17). Both groups rated the child’s oral health inferior to overall health rating (p<0.001). The authors concluded that disparities exist between the two groups in parental perceptions of their children’s oral health status and dental service utilization.
PMCID: PMC3106150  PMID: 19573042
Dental care; health status; health care disparities; parental perception; special education; child
17.  Social Disparities in Dental Insurance and Annual Dental Visits Among Medically Insured Patients With Diabetes: the Diabetes Study of Northern California (DISTANCE) Survey 
Preventing Chronic Disease  2010;7(3):A57.
People with diabetes are at increased risk of periodontal disease and tooth loss. Healthy People 2010 set a goal that 71% or more of people with diabetes should have an annual dental exam.
We assessed dental insurance and annual dental visits among dentate respondents from the Diabetes Study of Northern California (DISTANCE) Survey cohort (N = 20,188), an ethnically stratified, random sample of patients with diabetes aged 30 to 75 years receiving medical care from Kaiser Permanente Northern California. We calculated predicted probabilities for an annual dental visit (PPADV) by using regression models that incorporated age, sex, education level, annual household income, and self-reported race/ethnicity, stratified by whether the respondent had dental insurance.
Among 12,405 dentate patients, 9,257 (75%) had dental insurance. Annual dental visits were reported by 7,557 (82%) patients with dental insurance and 1,935 (61%) patients without dental insurance. The age-sex adjusted odds ratio for an annual dental visit was 2.66 (95% confidence interval, 2.33-3.03) for patients with dental insurance compared to those without dental insurance. For patients with dental insurance, the PPADV was 71% or more for all except those with the lowest household income. In contrast, for those without dental insurance, the PPADV was less than 71% for all except those with the most education or the highest income. We found some racial/ethnic subgroups were more likely than others to take advantage of dental insurance to have an annual dental visit.
Patients with diabetes in this managed care population who lacked dental insurance failed to meet the Healthy People 2010 goal for an annual dental visit. An increased effort should be made to promote oral health among people with diabetes.
PMCID: PMC2879989  PMID: 20394696
18.  Oral health-related cultural beliefs for four racial/ethnic groups: Assessment of the literature 
BMC Oral Health  2008;8:26.
The purpose of this study was to assess information available in the dental literature on oral health-related cultural beliefs. In the US, as elsewhere, many racial/ethnic minority groups shoulder a disproportionate burden of oral disease. Cultural beliefs, values and practices are often implicated as causes of oral health disparities, yet little is known about the breadth or adequacy of literature about cultural issues that could support these assertions. Hence, this rigorous assessment was conducted of work published in English on cultural beliefs and values in relation to oral health status and dental practice. Four racial/ethnic groups in the US (African-American, Chinese, Filipino and Hispanic/Latino) were chosen as exemplar populations.
The dental literature published in English for the period 1980–2006 noted in the electronic database PUBMED was searched, using keywords and MeSH headings in different combinations for each racial/ethnic group to identify eligible articles. To be eligible the title and abstract when available had to describe the oral health-related cultural knowledge or orientation of the populations studied.
Overall, the majority of the literature on racial/ethnic groups was epidemiologic in nature, mainly demonstrating disparities in oral health rather than the oral beliefs or practices of these groups. A total of 60 relevant articles were found: 16 for African-American, 30 for Chinese, 2 for Filipino and 12 for Hispanic/Latino populations. Data on beliefs and practices from these studies has been abstracted, compiled and assessed. Few research-based studies were located. Articles lacked adequate identification of groups studied, used limited methods and had poor conceptual base.
The scant information available from the published dental and medical literature provides at best a rudimentary framework of oral health related ideas and beliefs for specific populations.
PMCID: PMC2566974  PMID: 18793438

Results 1-19 (19)